Substance Use Disorder is a public health crisis. In 2017-18, there were 268,390 individuals in contact with drug and alcohol services in the UK.[1] This number pertains to people who were in contact with treatment services, not taking into account those who were not in contact.

Even after treating an addiction, there is still the chance of relapse, so how do we orient our treatment models so they are as effective as possible in treating the disorder and preventing relapse?

Drugs of abuse change the structure and functioning of the brain, resulting in changes that persist long after the drug use has ceased.[2] In order for treatment to be effective in the long term, it needs to address not only the drug use, but any medical, social, and psychological and legal problems that a patient might be subject to. It should also be appropriate to the age, gender, and cultural background of the patient.

The goal of addiction treatment is not only to get a person to stop using, but also to help them integrate back into society after beginning the road to recovery. It’s important to tackle the addiction and its associated behaviours, like compulsive drug seeking and use, but in order to fully, successfully recover, the treatment should also serve to help the person become a functioning member of society and member of their family, to become more likely to be employed, and improving their medical conditions - psychologically and physically - which would have worsened as a result of substance abuse.

Current Treatment Models

Current treatment approaches for substance use disorders most often take place in rehab centres, where there is focus on restoring the person to health and normality. Treatment approaches in rehab include detoxification and withdrawal management, behavioural therapy and counselling - including individual and group therapy, education on addiction, evaluation of and treatment for mental health issues that co-occur with the addiction, like depression and anxiety, 12 step meetings and long term follow-up care to reduce the risk of relapse, all stemming from an initial admission to a rehabilitation centre where the addict receives residential care.

In order for recovery to be a success, patients should have access to a range of care within a tailored treatment program, with follow-up care in place after primary treatment, which may include family-based support systems and/or community based support such as local drug and alcohol services or recovery support groups such as the 12 step fellowships or SMART recovery. Rehab centres will offer the services mentioned above in a controlled and supervised environment to ensure the stages of recovery are followed through.

Medication and Managing Withdrawal

One of the most difficult tasks in ceasing to use drugs of abuse is dealing with the withdrawal symptoms that follow. The intensity of these symptoms varies between individuals, depending on the type of substance used, how long it was used for, the individual’s age, their physical and psychological characteristics, and the means by which they stop using. Obviously, quitting cold turkey will cause a bigger shock to the system than a gradual stop.

In some cases it can be lethal.

General symptoms of withdrawal include:

  • Irritability
  • Insomnia
  • Changing moods
  • Depression and anxiety
  • Body aches and pains
  • Fatigue
  • Cravings
  • Nausea
  • Hallucinations

More severe withdrawal symptoms can include paranoia, confusion, tremors, and disorientation.

During treatment, the first step is to detoxify the body of the substance. This can be done naturally or with medical intervention. To cope with withdrawal symptoms during this time, medications can be used.

In treating Alcohol Use Disorders (AUD), benzodiazepines like Valium and Librium are used, which work by slowing down the central nervous system (CNS), which in turn reduces the severity of convulsions and tremors that come after cessations of use. However, benzodiazepines are highly addictive, and are mainly recommended for short-term use.

Opioid addiction, which, aside from heroin, is associated with prescription painkillers like morphine, hydrocodone, oxycodone, and codeine, can result in difficult withdrawal symptoms, including fatigue, nausea, irritability, anxiety, and restlessness, to name a few. Medications that are used to detox and treat withdrawal symptoms from opiates fall into two categories - opioid agonists and opioid antagonists.[3]

Methadone is an example of an opioid agonist that is used to detox from heroin. Agonists work by binding to the opioid receptors in the brain, stimulating the neurotransmitters to mimic the heroin high, relieving craving and withdrawal symptoms.

Naltrexone is an example of an opioid antagonist. Antagonists work by blocking the brain’s opioid receptors, preventing the neurotransmitters from being stimulated. This essentially blocks the body’s ability to get high, decreasing cravings. Antagonists are generally used post-detox, with the aim of preventing relapse[4].

Anxiety and depression are common withdrawal symptoms of many substances, and are often co-occurring disorders when there is an addiction. These conditions are difficult to deal with and can lead to suicidal tendencies in a person if not treated properly. To treat these conditions, practitioners often prescribe antidepressants, which are often effective in combating these symptoms.

Therapy

During rehabilitation, patients attend behavioural therapy sessions - individually or in groups - to help them address problematic behaviours and develop coping strategies. In many rehabs, patients also get involved in 12-step programs that teach patients the principles of acceptance, surrender, and involvement in recovery.

Cognitive Behavioural Therapy (CBT) is a common type of therapy used in treating addiction disorders.

CBT works by helping patients anticipate problems and enhance their self-control. In CBT, patients are taught techniques to address their own issues and help themselves, like exploring the pros and cons of continued drug use, self-monitoring to recognise cravings and impulses in their early stages and to identify risk-of-use situations, and strategies for coping with cravings and avoiding risk-of use situations.

Research has shown that the skills and techniques that a patient learns through CBT remain with the individual after treatment.[5]

Follow Up Treatment

At the end of residential rehab, patients are sometimes recommended to stay in sober transitional housing, which helps in the reintegration back to society. There is still much stigma around addiction in society, so these transitional living situations can help a person gradually move from inpatient to outpatient care without being overwhelmed by society's demands. Within residential care, patients must adhere to strict routines and regulations, but afterwards these routines are no longer in place, meaning there is a higher risk of relapse. Support groups and group or individual therapies are still available to the person at this stage of treatment, as this is a crucial time on the road to recovery.

Residential vs, Outpatient Treatment

During a residential treatment program, patients will experience the following advantages and disadvantages (although whether they are advantages or disadvantages may come down to perspective more so than fact).

Advantages of residential rehab include; being part of a community within the centre, receiving a high and intense level of care, and having a lot of time on a daily basis to focus on recovery. However, all of this also means that a patient can’t jump in and out of treatment. A stay must be completed, if not, then treatment is not completed. One’s day is also completely planned out in terms of waking up, eating, exercising, and therapy. It is almost as though you are living in a bubble and not having to deal with the stressors of daily life. Attending residential treatment means you will likely have to take leave from work and arrange for childcare if needs be.

In an outpatient setting, some of the advantages include: the freedom to resume with many aspects of your daily life, like work and family time and hobbies. It is generally a more affordable option. On the other hand, in an outpatient treatment program there is the risk of exposure to the substance and the triggers that led you to use. There is also less access to and time spent with therapists and counsellors, and the group bonding that creates a strong support network in residential programs does not necessarily occur to the same degree.

Education on what type of treatment is available is important and should be readily available. There are distinct differences between residential and outpatient treatment, and what best suits one person may not be the right option for another.

Room for Improvement

Rehab involving detox and therapy is effective in the short term, but where improvement is needed is in the care provided after residential treatment, the accessibility of treatment services, and in the level of public awareness on addiction.

Many rehab centres claim success based on completion of the program, but don’t take into account the rates of relapse after treatment.

Follow up care needs to extend far beyond the first days or weeks after rehab has been completed. Former inpatients should have access to support groups and therapy for years after their initial stay, as recovery is a life-long process.

Those in recovery benefit greatly from meditation practices and connection to others. Meditation practices cultivate mindfulness in individuals, which can help them detach from the ego and gain a more objective view of reality. Addiction can be very lonely, and is often exacerbated by a lack of connection to others. This is why community and family support groups are so important.

Improvement could also be seen in the level of accessibility to care. Rural areas are at a disadvantage when it comes to care as there are less professional and community resources available. Those who are suffering from poverty and homelessness on top of their addiction are limited in their resources and are unlikely to be able to afford the care they need.

Other than addressing the specific issues of those with addiction disorders, the overall effectiveness of treatment could be improved by public education. It is difficult for those in recovery to reintegrate back into society while there is still so much stigma surrounding drug use and addiction. By educating the public on what addiction really is, increasing awareness of how addiction occurs and its effects on the individual's brain functioning, and addressing harmful terminology that is often used - such as alco, junkie, and crackhead - we can reduce the stigma surrounding addiction and make it easier for those in recovery to continue on their journey and be successful.